|Previous Section||Back to Table of Contents||Lords Hansard Home Page|
Lord Low of Dalston: My Lords, I will be briefer than but have a good deal of sympathy with the noble Lord, Lord Harris, who has just spoken. It seems that the consumer's voice in the health service has been progressively watered down since the days of community health councils-almost to the point of extinction in the legislation before us. As is clear from the debate, there are many concerns over the question of independence, nowhere more than in relation to the proposed structure in which, as I understand it, there is no longer to be a distinct healthwatch organisation. Rather, local authorities will be able to put the local healthwatch functions out to tender on a piecemeal basis.
I apologise to noble Lords but my technology is playing up a bit today. Concerns have particularly focused on the threat to independence which might arise from the possibility that, in the current climate, local authorities will seek to retain some of the healthwatch funding for other purposes, given that it is not ring-fenced. The proposed funding regime is the same that obtains for LINks-that is, from central government via the local authority. We can perhaps gain some idea of the credibility of the concern by considering what has happened in relation to LINks funding.
In a study of LINks funding for the current financial year, the National Association of LINks Members revealed that most LINks had their funding cut. An informant from my local LINk told me that after discussion that he has had with other LINks it would appear that a number of local authorities will keep the funding of LINks for 2012-13 at the same level as for the present year. The effect is that while the Department of Health may have increased the funding of LINks to allow for inflation, that is not being passed on. He says that in respect of his own LINk in Hackney, in 2010-11 it received £206,000, which represented the whole amount of the funding provided by the Department of Health. In 2011-12, only £100,000 was provided, and the same amount will be provided for 2012-13.
In relation to the argument that local authorities may retain some of the funding for HealthWatch, the Government argue that local authorities will be under a statutory duty to fund HealthWatch. That may be true, but local authorities are currently under a similar duty in relation to LINks and that has not stopped them cutting LINks budgets. For that reason, as well as for conflict of interest and status reasons, HealthWatch needs to be a consolidated, coherent and independent body with standing-or at least, as a minimum, to have a ring-fenced budget.
Baroness Wheeler: My Lords, on behalf of these Benches, I want to express our concern and exasperation at these cobbled-together, last-minute changes to the status and organisational arrangements for local healthwatch. We are utterly opposed to depriving local healthwatch of its statutory status. It is hard to see the logic behind the new approach, even for those of us who are supportive of the local development of social enterprises.
The noble Baroness has not explained why this last-minute change is taking place 14 months into the consideration of the Bill. Why was this new approach
8 Mar 2012 : Column 1987
The Government's argument is that the new arrangements will provide local authorities with the flexibility that they need in establishing healthwatch organisations and facilitating their networking with other local community organisations. In practice, this means that not only will each local healthwatch be very different, and it will take more than the proposed national kite mark to provide them with any joined-up coherence, but they will all develop at a very different pace as local authorities take time to decide on the form of structure, and then draw up and implement their commissioning arrangements, or further subcontracting arrangements, if they want to make things really confusing, and so on. This is hardly the smooth transition from LINks organisations to the proper and coherent structure of patient representation at local level that we need. Like so much in this Bill, what could be simple and straightforward is made fragmented and complicated and requires detailed explanation. The Government also make strong play of local healthwatch organisations having a statutory function through a seat on health and well-being boards, through making a contribution on that board and the statutory joint strategic needs assessments and the joint health and well-being strategy. healthwatch will also have statutory status through the statutory health and well-being boards' ability to refer back to the NHS Commissioning Board plans that do not meet the needs of the local communities. So we have a second-hand, reflected statutory authority by participating in bodies that have statutory status.
It is interesting, too, that with clinical commissioning groups the Government have repeatedly argued that the Bill was needed to enable CCGs to be statutory bodies in their own right. Now we see exactly the opposite argument when it comes to patient representation.
Finally, there is the relationship of local healthwatch with the local authority, where there is again huge potential for conflict of interest, and concern that even the well intentioned authorities facing severe budget cuts could struggle to find the required funding for healthwatch organisations. Government amendments to address this and potential conflicts of interest by requiring local authorities to,
do not provide the safeguards that would be needed to ensure that patients, their carers or representatives should be able to expect if they are concerned that their complaint about a social services department is channelled through a non-statutory body funded and linked to the local authority itself.
As with the rest of the Bill, these are complicated structures understood and supported by no one, with details fleshed out at the last minute and sprung upon the House, in effect, only three working days before we are due to consider them, and with no opportunity for consultation on such fundamental change. Arguably
8 Mar 2012 : Column 1988
I hope that even at this late stage the Minister will acknowledge the concern, confusion and demoralisation, particularly among key patient organisations and groups, at the last-minute decision to change the status of local healthwatch organisations. I hope that she will agree to withdraw these amendments and instead restore statutory status to local healthwatch, enabling them to be organisations that everyone can rely on to be genuine patient representatives, fully trusted and supported by patients and the public.
Baroness Northover: Again, my Lords, what shines through is a great commitment to public and patient involvement at a local level; the only dispute is over the form of that. Again, noble Lords are familiar with the fact that various models have been tried, and I emphasise once again that we are seeking to build on the strengths of what has worked and mitigate some of the problems that have been encountered.
My noble friend Lady Jolly has tabled Amendments 234 and 235, the result of which would be to replace references to "people" with "local people" in Section 221 of the 2007 Act and insert the definition of "local people". We talked about the difficulty of organisations- LINks in particular-reaching groups that were defined as hard to reach. The definition in my noble friend's amendment says that when carrying out its functions, local healthwatch has to be representative of people who live in the area, service users and people who are representative of the local community. That applies to people of all ages and emphasises the need for local healthwatch to champion the views of the whole breadth of the local community. I am therefore grateful to my noble friend for this contribution, and I am happy to support her amendments.
Although I am sympathetic to the sentiment behind my noble friend Lady Cumberlege's Amendments 232, 236 and 237, I hope I can reassure noble Lords that, as corporate bodies, local healthwatches will have the flexibilities to make their own arrangements for securing staff, accommodation and so on, so the local authority should not have to make such arrangements on their behalf. There is no need for express provision on payment of expenditure because the legislation requires local authorities to make arrangements to ensure that the relevant activities can be carried on in their area. Necessarily, that means providing adequate funding to enable the functions to be carried out. This is an important point that I hope reassures noble Lords: the statutory functions must be delivered, and that is a protection of these bodies.
My noble friend Lady Cumberlege is quite right about local healthwatches working out their own priorities and work, and they will no doubt be doing that in conjunction with what is found to be good practice around the country, information coming from HealthWatch England and so on. I assure my noble friend that staff are there to help to facilitate such work, not to dominate it. My noble friend Lady Jolly
8 Mar 2012 : Column 1989
My noble friend Lady Cumberlege was concerned that government amendments would damage local healthwatch's independence. I do not agree: the amendments do not dilute in any way the statutory functions of local healthwatch, including the ability to give advice to local authorities among others. In response to concerns that local authorities may try to suppress local healthwatch, we specifically brought forward Amendment 236E giving the Secretary of State the ability to publish conflicts of interest guidance that both local authorities and local healthwatch would have to have regard to.
The noble Lord, Lord Harris, raised a number of issues. He regretted the fact that yesterday he was not at the seminar that I mentioned. I regret that he was not there. It was interrupted by a couple of votes, but I am sure that he would have engaged with those who were speaking there. That would have helped to inform everybody. All Peers were invited and some from his group attended. I see a few shaking heads.
Baroness Thornton: The noble Baroness might like to check with the Box. I informed the noble Earl's office of the times of our group meetings at the beginning of proceedings. Meetings and seminars have clashed all the way through.
Baroness Northover: I am very sorry if that is the case. I would hope that we would be able to have other such meetings. As these arrangements are taken forward, it would be extremely useful to have people's engagement. I was extremely glad that, even in such a clash, the noble Baroness, Lady Wheeler, and her noble friend were there.
The noble Lord, Lord Harris, should have received the letter about the amendments, but I gather that he thought he had not. A letter and briefing notes were sent to all Peers when the amendments were tabled and a full narrative of local healthwatch policy has been published on the Department of Health website. If the noble Lord has not seen the letter then I will feed that into the department to make sure that he receives this information so that he has it at his fingertips when he is contacted late at night by people who email him with concerns.
As I have mentioned before, it is very important that the local healthwatch seeks out views right across the area. It is an important factor in this arrangement that the local healthwatch will have a seat on the health and well-being board. I hope that that will help to reassure people of the influence of local healthwatch.
The noble Lord, Lord Harris, talked about privatisation by so-called social enterprises, or he flagged that up as a concern. I emphasise that the Government are huge fans of social enterprises, which perform a range of roles across the NHS. Social enterprises such as Turning Point are, of course, extremely valuable. This is not about privatisation or competition, as I feel we have made very clear.
The noble Lord, Lord Harris, also referred to my noble friend Lord Howe. My noble friend's concern in 2007 was that local LINks should have at least a basic structure of governance. That is precisely the concern that has led us to propose that local healthwatches should be social enterprises. The question of governance is quite separate from the question of whether or not an organisation should be statutory. Perhaps the noble Lord, Lord Harris, can enter dialogue with my noble friend Lord Howe on all of that in due course.
The noble Lord, Lord Harris, also asked about the possibility of there being more than one local healthwatch. Only one local healthwatch will be permitted for each local authority area. Each local authority will be able to make only one contract. If the local healthwatch wishes to subcontract some of its functions it can do so if the local authority permits, but the functions would still remain the responsibility of the local healthwatch. I hope that that clarifies the position.
Lord Harris of Haringey: I was trying to establish whether it would be possible, under these amendments, to segment the various functions of local healthwatch and contract them separately. I think the noble Baroness has just confirmed that. Am I right?
Baroness Northover: The key fact is that there is one local healthwatch for any local authority area. If it decides that it wants to subcontract something to best achieve what it needs, that is up to that local healthwatch. The noble Lord might want to bear in mind the statutory functions of local healthwatch and its responsibilities as eyes and ears. If it was not working, I am sure that noble Lords such as he would flag that up. Local healthwatch would then have to justify what it was doing and might need to move away from it.
I realise that time is pressing and it is a Thursday afternoon. I have listened to the concerns expressed about the need for local healthwatch to have strong lay involvement. I completely agree. This will be vital to the success of local healthwatch. Therefore, I confirm to the House today that we will use the power of the Secretary of State to specify criteria, which local healthwatch must satisfy, to include strong involvement by volunteers and lay members, including in its governance and leadership. This will have the effect that a local authority cannot award a local healthwatch contract to a social enterprise unless this condition is satisfied. I hope that that provides reassurance to noble Lords. My noble friend Lady Jolly also flagged this up.
The noble Lord, Lord Low, the noble Baroness, Lady Wheeler, and others raised the issue of funding for local healthwatch. It is important that local authorities can manage local priorities, since they are best placed to respond to their local communities. Therefore, local healthwatch will remain within local authority funding mechanisms, as I mentioned earlier. This view was supported by the NHS Future Forum, which made clear in its Patient Involvement and Public Accountability report that it did,
I believe that there is consensus over our ambition for local healthwatch. We do not disagree about what we want it to do for people or to accomplish in order to raise the quality of care. I hope that I have reassured noble Lords that it is right for local healthwatch to be delivered at a local level by organisations that are accountable locally. To embed healthwatch in localism will not only enable the organisational form of local healthwatch to best meet the needs of the local population but better enable local healthwatch to play an effective role in feeding back people's views and promoting their involvement in the scrutiny and provision of local care services. I refer again to the positive reaction of several different local authorities and councillors who are very pleased that they will now be involved in many elements of the healthcare services, as they are in public health.
Baroness Northover: Like the noble Lord, I recognise that the organisations which are in place when change occurs are always concerned. LINks have rightly expressed concern about whether what they know works well in what they do will be taken forward. They are very open about the challenges that they faced and some of the areas in which they have not done as well as intended. I pay tribute to the then Government for trying to make the system work when it was set up. It was a reaction to what had been done before and a looser model. Everybody in the system wanted that to work as a model. However, I think that the noble Lord has admitted that it has not worked universally. It is therefore understandable that the relevant organisations expressed concerns. I hope that they will become involved in the new system and that what they have contributed-the volunteers among them have made an effective contribution in many areas-will feed into local healthwatch. With that, I hope that noble Lords will accept the Government's amendments.
(a) in each of paragraphs (a) to (c), before "people" insert "local", and
"(ga) making recommendations to that committee to publish reports under section 45B(3) of the Health and Social Care Act 2008 about particular matters;"
(a) people who live in the local authority's area,
(b) people to whom care services are being or may be provided in that area,
(c) people from that area to whom care services are being provided in any place, and
(d) people who are (taken together) representative of the people mentioned in paragraphs (a) to (c);"."
(1) The Commission may grant a Local Healthwatch organisation a licence authorising the use, in relation to the carrying on of activities under arrangements made under section 221(1) of the Local Government and Public Involvement in Health Act 2007, of a registered trade mark of which the Commission is the proprietor.
(2) A licence under this section may not provide for the grant of a sub-licence by the licensee other than a sub-licence authorising the use of the mark by a Local Healthwatch contractor in relation to the carrying on of Local Healthwatch arrangements.
(a) is a social enterprise, and
(b) satisfies such criteria as may be prescribed by regulations made by the Secretary of State.
(a) has the function of carrying on in A's area the activities specified in section 221(2), and
(b) is to be known as the "Local Healthwatch organisation" for A's area.
(2B) But the arrangements may authorise the Local Healthwatch organisation to make, in pursuance of those arrangements, arrangements ("Local Healthwatch arrangements") with a person (other than A) for that person-
(a) to assist the organisation in carrying on in A's area some or all of the activities, or
(b) (subject to provision made under section 223(2)(e)) to carry on in A's area some (but not all) of the activities on the organisation's behalf."
"(4) The arrangements must secure the result that Local Healthwatch arrangements will not be made with a body of a description specified in subsection (3) or with the National Health Service Commissioning Board.""
(a) a person might reasonably consider that it acts for the benefit of the community in England, and
(b) it satisfies such criteria as may be prescribed by regulations made by the Secretary of State.
(9) Regulations made by the Secretary of State may provide that activities of a prescribed description are to be treated as being, or as not being, activities which a person might reasonably consider to be activities carried on for the benefit of the community in England.
(10) In subsections (8) and (9), "community" includes a section of the community; and regulations made by the Secretary of State may make provision about what does, does not or may constitute a section of the community.""
(2) Arrangements under section 221(1) must require the Local Healthwatch organisation, in exercising its function of carrying on the activities specified in section 221(2) or in making Local Healthwatch arrangements, to have regard to any conflicts guidance issued by the Secretary of State.
(a) the making of arrangements under section 221(1), and
(b) the carrying-on of the activities specified in section 221(2).
(a) for "must require local involvement network arrangements to include" substitute "must include or (as the case may be) must require Local Healthwatch arrangements to include",
(b) in paragraphs (a), (c) and (d), for "a local involvement network" substitute "a Local Healthwatch organisation or a Local Healthwatch contractor", and
(c) after paragraph (d) insert ";
(e) prescribed provision relating to the activities which a Local Healthwatch contractor may not carry on on a Local Healthwatch organisation's behalf;
(f) prescribed provision relating to the obtaining by a Local Healthwatch organisation of a licence under section 45C of the Health and Social Care Act 2008 and the grant by the organisation to a Local Healthwatch contractor of a sub-licence;
(g) prescribed provision relating to the use by a Local Healthwatch organisation or a Local Healthwatch contractor of the trade mark to which a licence under that section relates;
(h) prescribed provision relating to the infringement of the trade mark to which a licence under that section relates;
(i) prescribed provision relating to the imposition of a requirement on a Local Healthwatch organisation to act with a view to securing that its Local Healthwatch contractors (taken together) are representative of-
(i) people who live in the local authority's area,
(ii) people to whom care services are being or may be provided in that area, and
(iii) people from that area to whom care services are being provided in any place."
(a) only in so far as it assists the Local Healthwatch organisation in the carrying on of activities specified in section 221(2);
(b) only in so far as it carries on such activities on the organisation's behalf.
(2B) Regulations under this section may make provision which applies to all descriptions of Local Healthwatch contractor, which applies to all those descriptions subject to specified exceptions or which applies only to such of those descriptions as are prescribed."
(a) before the definition of "a local involvement network" insert-
(b) omit the definition of "a local involvement network",
(c) for the definition of "local involvement network arrangements" substitute-
(d) after that definition insert-
(e) after the definition of "prescribed provision" insert ";
"( ) a complaint under section 73C(1) of the National Health Service Act 2006;
( ) a complaint to a Local Commissioner under Part 3 of the Local Government Act 1974 about a matter which could be the subject of a complaint under section 73C(1) of the National Health Service Act 2006; or"
"(a) a person providing services under arrangements under this section;
(b) a person arranging for the provision of services in pursuance of arrangements under this section;
(c) a person providing services under arrangements made in pursuance of arrangements under this section."
"(b) in compliance with a requirement imposed by virtue of section 223(2)(i)."
"(3A) For the purposes of subsection (1), something is done by a Local Healthwatch contractor if it is done by that contractor in the carrying-on, under Local Healthwatch arrangements, of activities specified in section 221(2)."
"(7A) For the purposes of this section, something is done by a Local Healthwatch contractor if it is done by that contractor in the carrying-on, under Local Healthwatch arrangements, of activities specified in section 221(2)."
"(ii) omit ", for each local involvement network,""
"(iii) for "the network", in the first place it appears, substitute "the Local Healthwatch organisation",
(iiia) for "the network", in the second place it appears, substitute "the organisation","
"(c) omit sub-paragraph (ii),"
238ZZF: Clause 187, page 186, line 13, leave out "or H in respect of the organisation" and insert "in its capacity as such, and the amounts spent by its Local Healthwatch contractors in their capacity as such,"
"(3) A scheme under this section may make provision for rights and liabilities relating to an individual's contract of employment; and the scheme may, in particular, make provision which is the same as or similar to provision in the Transfer of Undertakings (Protection of Employment) Regulations 2006 (S.I. 2006/246).
(a) whether or not they would otherwise be capable of being transferred;
(b) irrespective of any requirement for consent that would otherwise apply.
(a) treated as done by or in relation to the transferee or its employees;
(b) continued by or in relation to the transferee or its employees.
"(bl) Local Healthwatch organisations, as regards the carrying on of activities specified in section 221(1) of the Local Government and Public Involvement in Health Act 2007 (local care services);".
"Director of a Local Healthwatch organisation."
"Director of a Local Healthwatch organisation."
(a) arrangements made under section 221(1) of the Local Government and Public Involvement in Health Act 2007, or
(b) arrangements made in pursuance of arrangements made under section 221(1) of that Act."
"(e) a Local Healthwach organisation;".
(a) in subsection (1)(c)-
(i) for "local involvement networks" substitute "Local Healthwatch organisations or Local Healthwatch contractors", and
(ii) omit "in their areas".
(b) for subsection (3) substitute-
"(3) In subsection (1)(c), "Local Healthwatch contractor" has the meaning given by section 223 of the Local Government and Public Involvement in Health Act 2007.""
Lord Ramsbotham: My Lords, I shall be brief. First, I pay tribute to the noble Earl, Lord Howe, and thank him very much for his letter on this subject. I declare an interest as chairman of the All-Party Group on Speech and Language Difficulties. We have been campaigning in many Bills-education, welfare and justice-to make certain that every child is properly assessed not just for learning disabilities but for learning difficulties and particularly to enable every child to engage with the education system. The Minister has assured me that health visitors are being trained by speech and language therapists to enable that to be done. I hope very much that this will soon be the norm throughout the United Kingdom. Therefore, Amendments 238A, 238B, 238C, 238D and 238E add a little more to the debate that we had at earlier stages of the Bill.
In particular, I am anxious to make certain, if we possibly can, that the variability in commissioning between local areas is reviewed. In her recent report, the communications commissioner, Jean Gross, stated that there was considerable variety and that she expected to find such commissioning in only 70 per cent of local areas. This is unfortunate. I do not think it is right that there should be a postcode lottery in assessing our children's ability to engage with education.
I introduce the words "allied health professional" in Amendment 238B because the allied health professionals have responsibility for liaising between the primary and secondary sectors and therefore cover a wide number of disciplines. I include the words "education or children's services" in Amendments 238C, 238D and 238E in order to make certain that those services, along with the NHS and local government, are properly represented in ensuring that this opportunity is available to every child throughout the United Kingdom.
I appreciate that it may not seem appropriate to make these amendments to the Bill. However, I hope that the Minister will be able to assure me that these
8 Mar 2012 : Column 2002
Baroness Whitaker: My Lords, in supporting the noble Lord, Lord Ramsbotham, I have very little to add, which I imagine will be welcome to noble Lords at this hour. He has really said it all extremely comprehensively but I would just add that, if the Bill cannot provide the framework that these amendments would ensure, particularly in respect of integration of the education services, children in particular will suffer. I briefly remind noble Lords that speech and language deficits are among the most common disabilities in childhood. They affect significant numbers, who will lose out on education, employment and relationships as a result. I hope that the noble Earl will be able to provide the reassurances that we seek.
My amendments would require all health and well-being boards to take a local lead on integrating health-related services with health and social care. General duties to promote such integration are held by the NHS Commissioning Board and clinical commissioning groups. The amendments would ensure that health and well-being boards also played their part.
Integration of the planning and delivery of health and social care with health-related services is crucial for improving the health and well-being of local populations. Evidence and experience show that health and care services can be made more effective, efficient and accessible when integrated with wider support services. The Bill references this network of support as "health-related" services. This covers a wide range of provision that contributes to children's and adults' health and well-being. The National Children's Bureau, the National Housing Federation, St Mungo's and Homeless Link have come together to call for a clear role for health and well-being boards and they support close integrated working between health-related services and health and social care. This is clearly an issue that has implications across all sectors-health, education, children, housing and employment.
As the Bill stands, clinical commissioning groups and the NHS Commissioning Board will have a general duty to promote integration of health services with health-related services, as well as with social care. Health and well-being boards' duties to support close working and partnership arrangements are limited to health and social care, with only a power to encourage close working with health-related services.
I am concerned that, without the support of their local partners through health and well-being boards, the NHS will struggle to deliver on this wider integration agenda. As health and well-being boards will be the key forums for local partnership working, they should have duties in this regard; for example, with children and young people. Schools and colleges, children's centres and youth services are vital settings for delivering health outcomes. The national evaluation of Sure
8 Mar 2012 : Column 2003
Evidence suggests that health, social care, education, early childhood, youth and other services are not always working in partnership to secure good health outcomes for children and young people. The Marmot review identified a lack of consistent partnership working between such bodies as a barrier to delivery. Similarly, the Kennedy review highlighted the fact that the requisite links between the NHS, social care, education and the criminal justice services to support children and young people are not always made. This report recommended that local partnerships, covering all services for children, should have a duty to ensure that local organisations work together. Close working between local partners is particularly vital for children with complex needs, such as disabled or looked-after children, who need co-ordinated interventions from a range of services.
Improving people's health is rarely achieved by clinical interventions alone, but is dependent on the wider determinants of health; for example, housing support acts as a health intervention and can help people to improve their well-being, manage their health better and prevent the need for more acute services. A lack of good housing can also be a major determinant of poor health: eight out of 10 homeless people have one or more physical health needs and seven out of 10 have at least one mental health problem. The average age of death of a rough sleeper is estimated to be 40 to 44 years.
I chair the National Treatment Agency for Substance Misuse and I am well aware that, in tackling drug and alcohol use, we also need to tackle the social issues such as housing, employment and education. The Marmot review, Fair Society, Healthy Lives, noted that,
The role of health and well-being boards in promoting integration across local services was debated in Committee on 19 December. The Government acknowledged the role that housing, schools and other services might play in promoting health and well-being.
However, in response to separate amendments aimed at strengthening the role of health and well-being boards in engaging and working with specific health-related services, the noble Earl, Lord Howe, responded:
The relevant statutory guidance has been published in draft form by the Department of Health. Although it makes broad references to vulnerable groups and wider services like housing, there are no clear expectations for how, when and where this integration could take place or which client groups or needs would particularly benefit from this. The Bill offers opportunities to integrate services beyond traditional primary and
8 Mar 2012 : Column 2004
The Earl of Listowel: My Lords, I support the amendment spoken to by my noble friend, to which my name is attached. I will strive to be as brief as possible at this late hour, but the issue is very important.
I will begin with an aside and refer to the short debate on productivity and manufacturing industry instigated at the start of business today by the noble Lord, Lord Bates. I will highlight the point made recently by Education Minister Sarah Teather that what happens in schools is important, but that the most important thing for children's success outcomes is what happens in the home, outside school. As one academic put it, when one considers what makes the difference to a successful outcome for a child, only 10 per cent of it will depend on schools; the rest will depend on what happens in the background, in the family.
Of course, whether a parent is successful in their education is the single most important indicator that their child will be successful in their education. Businesses might be more aware, when they push for schools to teach children to read, write and do arithmetic better to get their apprenticeship skills, that they should think also very much about early intervention and getting it right in the family as well. If we are to compete with China in future, we need to think very carefully about the successful integration of services to support families and children.
I will speak briefly, on International Women's Day, about another matter raised in an earlier debate today: namely, domestic violence and women fleeing to refuges. A few years ago I spoke to a child and adolescent psychiatrist, Professor Panos Vostanis of the University of Leicester. He had gone into these refuges and worked with the mothers and children over time, providing them with support. He said how important and effective it had been, but how rare the service was. He has now been commissioned by the European Union to conduct EU-wide research into support for families where there has been domestic violence.
This theme recurs in children's homes, refuges and other settings. It seems elementary that a mental health professional such as a psychiatrist or clinical psychologist should visit a children's home or refuge once a fortnight, to speak to mothers, work with children and support staff. That is best practice and it happens-but very often the model gets overlooked because, understandably, clinicians are under pressure and there are high thresholds of access for children and adults to these services.
Perhaps I may give one further example on the matter of schools. I recently attended an international conference on the mental health of children in schools. It was organised by Dr Rita Harris, head of child and adolescent mental health services at the Tavistock and Portman NHS Foundation Trust. We were given a presentation by two wonderful mental health nurses who had tried to revive a service in the Sunderland
8 Mar 2012 : Column 2005
The record is very poor. Given the concerns that many have raised in the past about the possible fragmentation that might arise from the Bill, and the many clinical commissioning groups that will come into being and the large upheaval that will take place, I am looking to the Minister for reassurance that the Government will improve a situation that has been so disappointing in the past, that we will see a better integrated service that will better meet the needs of children and families, that we will see better outcomes for children and they will be more successful in school in part because health and social care services will have been better integrated for them and they will have received, early in their lives, the support that they need. I look forward to the Minister's response.
These amendments relate to the membership of health and well-being boards. As currently proposed, the boards will have at least one councillor of the relevant local authority-so it could be one councillor, or it could be more. The choice will be with the council. However, several other people who have membership will be officers or unelected co-optees. This means that the board as currently proposed is effectively a board of directors, not a council committee which-unlike all other council committees-is made up of those who are publicly elected. Yet the board as proposed is legally a council committee; and because it is legally a council committee, only councillors can vote-officers must advise. For officers to vote, specific regulations will have to be put in place, and of course they can be. However, I hope that the Minister is willing to think further about this. Councillors, being elected, have both a democratic mandate-unlike officers-and a perception of service provision which comes from a geographical perspective as well as a service perspective. At times that can be very valuable, particularly in a geographically large council area.
To have just one councillor-which is what the Bill permits-would be a mistake. It would mean a council committee, the health and well-being board, would be dominated by officers and co-optees. It would also mean that only one political group was in membership of the board, which in my view would be deeply unwise.
Given the board's terms of reference, I do not argue that councillors have to be in majority. However, I do argue that councillors are important; that geographical differences in a council area should be acknowledged; and that more than one political group should be fully
8 Mar 2012 : Column 2006
In Committee there was a discussion about councillor membership-how many there should be, whether they should be in a majority and whether they should have powers over the budgets of other health organisations not managed by the council. There was no conclusion to that debate, but I have thought long and hard about it. I have concluded that the amendments in my name and those of the noble Lord, Lord Bichard, and the noble Baronesses, Lady Eaton and Lady Henig, which reflect all parts of this Chamber, give a solution to this problem and would enable us to balance professional knowledge with the necessary democratic accountability.
I do not propose to press this to a vote, but I hope that the Minister will be willing to engage in discussion on it. What is being proposed from all parts of the House is a solution to a problem that needs to be resolved. It will prevent difficulties arising further down the line should a council decide to have only one councillor as a member of the board.
Baroness Finlay of Llandaff: My Lords, I shall speak briefly to Amendment 238A, which is in the name of my noble friend Lord Ramsbotham. I rather hope that the Government will take on board its spirit, if not its actual wording. The reason is that in creating a joint strategic needs assessment, there will be a requirement for those involved to begin to work in a completely new way. Human nature is such that people tend to repeat the patterns of things they have done before. In addition, they do not know what they do not know. When they feel insecure, they are less-not more-likely to consult, because it is quite threatening to have to consult and go beyond the boundaries of what you thought you knew and discover all the things that you did not know.
person, without specifying who they are. It leaves it very broad but it pushes forward the boundaries. We have already discussed the problem of children. The difficulty, if people do not consult widely, is that if children miss out at a developmental stage and one aspect of their development-for example, motor development, speech and language development or emotional development-does not occur, they never catch up. It is missed out for good; they always lag behind.
It is really important to make sure that the provisions are there right the way through the trajectory from
8 Mar 2012 : Column 2007
Lord Beecham: My Lords, I will speak to my Amendment 238H, as well as amendments moved by other noble Lords. I am pleased to confirm that the Opposition entirely support the amendments moved by the noble Lord, Lord Ramsbotham, the noble Baroness, Lady Massey, and the noble Lord, Lord Shipley. Once again, I am pleased to say that Newcastle is united on the issue of the composition of health and well-being boards.
The only amendment about which I have not so much a reservation as a question is that to be moved by the Minister, Amendment 239, which refers to the possibility of a local authority giving permission to the health and well-being board to carry out,
I wonder whether the Government have borne in mind the fact that there is now a general power of competence for local government, and whether it is the intention of this amendment to embrace not only the statutory functions of local government as things that may be delegated to the health and well-being boards but anything that the local authority is empowered to do. Given that there is now a general power of competence, that would be a very wide remit indeed. It is not necessarily a wrong line to take but it would be interesting to know whether the Government have considered that potential implication, and if they have not-and I would not blame the Minister if he had other, more pressing things on his mind-perhaps he might come back to us at Third Reading or before.
I particularly welcome the amendments moved by the noble Lord, Lord Ramsbotham, because they raise the issue of children's services and health, which has to a significant extent been overtaken in this Bill by other considerations around traditional health services and adult care. I very much welcome those points.
In relation to the amendments moved by the noble Lord, Lord Shipley, I join him in thinking that it would be very helpful for the Government to send a signal as to the representation of elected members- not merely one, who could be regarded as a token, but a significant number. I would have gone perhaps slightly higher than three, but three would be a working basis.
In Committee, the Minister said that it is up to councils to decide the composition of these boards. That is true, but I think a signal would be welcome in that respect. I am particularly glad to join the noble Lord, Lord Shipley, in returning to a theme which I am afraid I have sounded more than once in debates over this Bill about the necessity for district authorities to be represented. It is a very important point in relation to the shire county areas.
The health and well-being boards are responsible for drawing up joint strategic needs assessments and the health and well-being strategies. The clinical commissioning groups collectively will be responsible for, I think, some £60 billion-worth of commissioning, which is a hugely important role in the national and the local context. It is important that there should be a mechanism by which that is brought closer to democratic accountability. Given that the health and well-being boards will embrace relevant partners, including clinical commissioning groups, it is right that their plans should be signed off by the health and well-being board.
Dr Evan Harris, in an interesting article in yesterday's Guardian, raised among other issues the lack of democratic accountability in this Bill. He has a point, which is particularly relevant in connection with the clinical commissioning groups, which are self-selected. As far as their decisions are concerned, they are not accountable as such. As the Bill stands, they would take the decision on the commissioning plan. They would have to have regard to the views of the health and well-being board but that would be the limit of it.
That raises a fundamental principle, to which I hope the Minister will be capable of responding positively. If not, I have to give notice that I would seek to test the opinion of the House. It is an important point to which I hope that he will respond favourably. I certainly hope that he will respond favourably to the amendments moved by others of your Lordships.
Earl Howe: My Lords, this group of amendments all relate to health and well-being boards and in particular their statutory minimum membership, responsibility for preparing both joint strategic needs assessments and joint health and well-being strategies, as well as their role in promoting integration.
Amendments from the noble Lord, Lord Ramsbotham, and my noble friend Lord Shipley, relate to changes to the statutory membership of health and well-being boards, which I know we have previously debated. As noble Lords will be aware, we have consulted extensively on the membership of health and well-being boards and one of the consistent messages we have heard is that local people want a balance between the flexibility to add members alongside some consistency in representation from key players, such as elected representatives and clinical commissioning groups.
The Future Forum looked at this and, following its report, we made a commitment that it will be for local authorities, or in some cases the leader or mayor, to determine the precise number of elected representatives on its board, although we have stipulated that there must be at least one. I would ask my noble friend Lord Shipley to note the words "at least one". We believe that it is right for local areas to be able to have the flexibility to determine the wider membership of their boards based on local need. I am of course happy, however, to engage with my noble friend in further discussions.
The Bill allows local areas the flexibility to develop the arrangements that best work for them. It is important to be clear that the purpose of this policy is not primarily about setting up a committee but about stimulating effective joint working for and with local
8 Mar 2012 : Column 2009
We can be encouraged by what is now happening on the ground. We know that a large number of local areas are already working with all the relevant stakeholders to explore and agree how they can work together in the future to make the biggest difference to local people. For instance, from our work with shadow health and well-being boards, we have had lots of feedback to suggest that two-tier county councils are working closely with district councils through the boards in a range of creative and positive ways based on local need and circumstances. In fact, I understand that in many two-tier areas, shadow boards are already operating with more than one district council representative ranging from the leader, the chief executive or a senior officer. However, developing these relationships and understanding how best everyone, whether it be district councils, health professionals, local providers or the voluntary sector, can contribute in the most appropriate way, is something that we feel strongly is best left to these conversations rather than being prescribed on the face of the Bill.
Amendments 238C, 238D and 238E, tabled in the names of the noble Lord, Lord Ramsbotham, and the noble Baroness, Lady Whitaker, relate to placing a particular emphasis on educational and children's services. They would make explicit reference to education and children's services in the Bill, in the context of the duty and powers of health and well-being boards, to encourage close working between the commissioners of health and social care services, with itself and with commissioners of health-related services in the area. I should like to take this opportunity to reiterate some of the points made during our previous debates on this topic. I fully agree that joining up health and social care services for children as well as for adults is crucial, but I believe that the existing provisions set out in the Bill are sufficient to ensure that the voices of children are heard. Indeed, I should like to remind noble Lords that in preparing the JSNA and joint health and well-being strategy, health and well-being boards will have a statutory duty to involve people who live or work in the area, and this will include within it young people. The director of children's services will be a statutory member of the health and well-being board to ensure that the needs of children are taken into account, and local healthwatch will also be able to use its membership on the boards to help ensure that the voices of the whole community, including those of young people, are fed in.
In addition, the statutory guidance-I think this is a reassurance that the noble Lord, Lord Ramsbotham, wanted-we are producing on JSNAs and joint health and well-being strategies will emphasise the importance of understanding and addressing the needs of children and young people. We are also supporting the efforts of local partners by bringing together emerging health and well-being boards into a national learning network, which is developing ways to engage effectively with local people, including a focus on effective joint working to improve services for children and families.
Baroness Whitaker: I am sorry to interrupt the noble Earl, but before he moves off our amendments, I did not actually hear the words "education services" in his helpful remarks. Could he explain how they will come in?
Amendment 238A would require local authorities and CCGs to specifically consult relevant health professionals when preparing the JSNA. As I have said before, in preparing the JSNA and joint strategy, local authorities and CCGs will be under a duty, which the health and well-being boards will discharge, to involve people who live or work in the area. In practice this could well include health professionals. Indeed, I thought that the noble Baroness, Lady Finlay, made a powerful point in this regard, and I do feel that we are broadly accepting the spirit of the amendment.
In relation to Amendment 238AZA in the name of the noble Baroness, Lady Massey, and the noble Earl, Lord Listowel, I should like to reassure both of them that the health and well-being strategy will be a shared, overarching response addressing the health and social care needs of an area identified through the JSNA. In the joint strategy, the board will be able to consider how the commissioning of wider health-related services could be more closely integrated with health and social care commissioning. For example, the board could consider whether and how housing, education or local authority leisure services could affect health and, if they do, how commissioning could be more closely integrated with the commissioning of health and social care services. The model we have chosen for health and well-being boards is designed to enable those wider conversations to take place, and in answer specifically to the noble Earl, Lord Listowel, I genuinely believe that the arrangements in the Bill afford a much better chance of us having joined-up thinking and joined-up services than we have had before. Clinical commissioners will be best placed to work in the interests of children, especially when this requires working with other professionals. There are strong duties on commissioners as to promoting integration, as the noble Earl will be aware.
On Amendment 238H, in the name of the noble Lord, Lord Beecham, we believe that health and well-being boards will provide an opportunity to build strong relationships with an open culture of peer-to-peer challenge. The JSNA and joint strategy will provide all members with a common understanding of local needs and priorities. However, giving boards a power of veto over commissioning plans would undoubtedly undermine that relationship. I am afraid that we are firmly against that idea.
We are in agreement on that matter with the Future Forum and the Local Government Association, both of which recognise that placing a duty on CCGs to agree commissioning plans with the health and well-being boards would confuse lines of accountability and be unworkable-confusing and unworkable were the words of the Future Forum. CCGs are ultimately responsible for their budgets and to give the health and well-being
8 Mar 2012 : Column 2011
Finally, I should like to speak to the government amendment in this group, Amendment 239, which is a minor technical amendment in relation to Clause 195. The purpose of this amendment is to clarify that a local authority may delegate any functions exercisable by it to the health and well-being board. I hope that it will receive the support of the House.
Lord Beecham: I remind the noble Earl of my question about whether that extends to general powers of competence rather than statutory functions. I invite him to communicate later as I suspect that he may not be in a position to do that immediately.
Lord Ramsbotham: I thank the noble Earl for his habitually courteous and balanced reply and I am reassured on some of the points that I raised. I am grateful to the noble Baroness, Lady Whitaker, and my noble friend Lady Finlay in particular for supporting the amendments and to the noble Lord, Lord Beecham, for mentioning them. Like the noble Baroness, Lady Whitaker, I have this nagging fear that education, education, education is something that will need to engage the health and well-being boards. The link between education and health, particularly in the assessment, which was the subject of the amendments, is absolutely crucial. During the passage of the then Education Bill, noble Lords described what they wanted but of course they could not have it because they were health matters funded by health. Therefore, it is terribly important that joint working happens.
I was very glad that the noble Earl mentioned "effective joint working", because I am sure that that is what we all seek. That was what was behind each and every one of the amendments. On the basis of that and knowing the noble Earl and that if he says something it is usually likely to happen, I beg leave to withdraw the amendment.
All commissioning plans prepared by a clinical commissioning group as set out in section 14Z9 of the National Health Service Act 2006 must be agreed by the relevant Health and Wellbeing Board."
|Next Section||Back to Table of Contents||Lords Hansard Home Page|